Home Delivery Medicament Program: access, inactivity and cardiovascular risk

ABSTRACT Objective: to verify causes of inactivity in the Home Delivery Medicament Program, as referred by users from a Primary Health Care Service in São Paulo, comparing them to the causes registered in the program and analyzing them in the theoretical model Concept of Access to Health. Methods: cross-sectional study, interviewing 111 inactive users; and documentary study in the program records. Results: half of the users did not know the condition of inactivity. Discrepancies were found between the user's and the program's information, observing different levels of agreement: Absence of physician and administrative staff member 0%; Transfer to other service 25%; Death 50%; Option to quit 50%; Address change 57% and Change in therapeutic schedule 80%. The users' feeling of accepting the program was observed. In the health access concept, inactivity can be explained in the information dimension, in the degree of asymmetry between the patient's and the health professional's knowledge, identified through the indicators: education, knowledge and information sources. Conclusions: due to the low education level, the user does not assimilate the information on the steps of the program flowchart, does not return for the assessment that guarantees its continuity. Consequently, (s)he stops receiving the medication and spends a long time without treatment, increasing the cardiovascular risk of hypertensive (92% of the sample), diabetic (44%) and dyslipidemic patients (31%).


Introduction
The change in the morbidity and mortality profile due to chronic illnesses and cardiovascular complications, such as acute myocardial infarction and stroke, has redirected public and scientific health care policies (1) .
Concomitantly with the international guidelines (2)(3) , with the attempts to find evidence in order to understand the low treatment compliance rates (4) and with governmental programs and the supply of services to reduce the high prevalence rates of these problems, several authors have made efforts to understand and discuss the Health Access concept. for experts on the theme (5) . The focus turned to the characteristics of the population, emphasizing the importance of individual determinants like income, health coverage, attitudes towards care and social structure (6) .
The concept of health access gained consistency through the aggregation of socio-organizational attributes like the social, cultural and educational condition, variables that could be assessed by means of outcome indicators of the user's passage through the system, such as user satisfaction, an attribute that was also highlighted at the start of the 1980's (7) . Different authors have revised the concept of health access in the 21 st century (8)(9)(10) , considering four dimensions that can be assessed by means of process and outcome indicators, which help to judge the conditions of equity or inequality in the access to health: availability; acceptability; capacity and information (11) .
Recent studies on medication access are scarcer, although the World Health Organization (WHO) has published on the theme (12)(13) .
The objective in this study is to understand why the Home Delivery Medicament Program, an example of an easily available access to medication treatment, registers high inactivity rates. The authors considered that analyzing the reasons for the apparent dropout of The objective was to guarantee medication access and continuing care for patients suffering from these conditions, through the home delivery of sufficient drugs for 90 days (15) .
At first, the HDMP prioritized Diabetes and/or Arterial Hypertension patients, in stable and clinically controlled conditions, monitored at Primary Health Care Units (PHCU). Later, patients with dyslipidemias and thyroid problems were included.
In a PhD study on medication access by the lowincome population in a neighborhood of São Paulo, it was concluded that picking up medication at the desk of the PHCU demanded time, money, frustration and increased the rates of absence from work. Besides receiving the drug at home, the users were guaranteed a scheduled return appointment and further tests for control. The author concluded that the HDMP resulted in lesser risk of problems, a better bond with the team, in addition to the fact that the users felt more valued and taken care of (Unpublished data). Nevertheless, in recent years, the leaders have been facing high levels of inactivity in the program, with information on why the users dropped out of the program.
The objective in this study was to identify the users' reasons to drop out of the Home Delivery Medicament Program, to compare them to those registered electronically at the PHCU in the program files and to analyze the results in view of the current Health Access concept.

Method
Cross-sectional, analytic, documentary field study, undertaken at a Primary Health Care Unit in the North of the City of São Paulo. although the interviewer was the manager of the PHCU in question, difficulties to establish telephone contact were expected, which are common in recent times, for reasons of social protection as well as information constraints. Nevertheless, mentioning some data from the patient history, demonstrating knowledge about the user was a strategy that facilitated the initial contact.
Data analysis: to understand and discuss the reasons for activity, it was fundamental to analyze the users' inclusion in the HDMP flowchart, the sociodemographic characteristics and to analyze the results based on the concept of Health Access, described in four dimensions (4) .
These were presented here because they represented an interesting theoretical model to discuss the data after the most recent review by Brazilian authors (11) .

Results
During the interviews, data were revealed that  As verified in Table 1, women are predominant among the users. The population sample includes mainly elderly people, with two-thirds of the participants being over 60 years of age and having a low education level.  Table 2.
Yes = presence of the disease; No = absence of the disease. The data in Table 2  feelings about the program were expressed strongly (Table 3).   The lack of agreement between the HDMP records and reports of the inactive users in Table 4

Discussion
From the methodological viewpoint, one could expect that the telephone interview would restrict the information. That did not happen, probably because many participants were informed of their inactive status in the HDMP when they received the ethical details of the protocol, such as the aspect inherent in the consent to participate in the research. The words "drop-out" or "no longer attending" the program were used to clarify the condition of "inactive", due to the education level.
The discovery of this condition provoked feelings that facilitate the information needed to reach the objectives.
The feeling of restricted access made some users feel abandoned, making them express their feelings about the HDMP and the information needed.
Concerning the sociodemographic variables, the gender data are in line with other studies undertaken at health services, where the number of female users surpasses that of male ones (16) , possibly due to the greater availability, considering that men tend to work until more advanced ages. Nevertheless, even after retiring (70 years), men do not reach the same compliance observed in women. Data from the Brazilian Institute of Geography and Statistics do not appoint differences between the sexes in the region studied (17) .
The advanced age of many inactive users was no surprise, due to the high prevalence of hypertension and diabetes mellitus after the age of 60 years, diseases prioritized in the program. Although the estimated prevalence of hypertension of 35.8% in men and 30% in women (14) , there are no exact studies that evidence a relevant increase in these percentages after the ages of 50-60 years.
The low education level found may have influenced the difficulty to understand the MHP orientations and standards, in line with other data found in São Paulo for hypertensive elderly, many of whom were illiterate (18) .
The education level is a variable highlighted in reviews on treatment compliance and worsening of chronic illnesses, and directly related to the socioeconomic conditions of the populations (19) .
In the analysis of education results in the health access concept presented in the method (11) the dimension information, the degree of asymmetry between the patient and the health professional's knowledge, is   (21) .
When discussing the human right to medication access and in view of the undeniable vulnerability of not granting this right to thousands of people around the world, in 2013, Moon considered the need to clearly establish the responsibilities of the government and the pharmaceutical industry and criticizes the weakness of terms in guidelines in the area, which "have to" instead of "need to" (22) . Hence, medication access and dispensation are still themes that require attention (23) .
In in line with authors who observed associations between lower education level and cardiovascular complications in patients with diagnoses similar to the present study (24)(25) . Therefore, the hypothesis is raised that a substantial part of inactive users who interrupt the drugs is vulnerable to cardiovascular complications.